31531 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPC'RTINO BUILDING•ELECTRICAL. PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 31531�I C N
BUILDINGPROJEC 11)]CNTIFICATION 315 .L
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
/0 3 TSO 6 U-3 Yl u C;e' V__ ` A,*. Z, i "Les,d2 A
OWN/EE''R11'S NAME: PHONE: CONTR CTOR'SN ME: LIC NO:
("'' r S MS NIC CONTROL is
ARCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
38v fl•�" « Ls�e
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEF.
1 hereby aRnn that I nm licensed undo previsions of Chapter 9(commencing JOB DESCRIPTION
�00 ithSmion7000)nf Division3ofthe Business and Professions Coda and mylicense is 410ADDITION
IDENTIAL:
OO n full farce and eif c l/ pQ^�5 '� PERMIT ISSUANCE
�Ul�,) Liccn� y,�,— Lic.p gl ❑SFDWL ❑KITCHEPLUMBINREMODEL
LF..ZZQul Dam LL Canvacmr u��/ �f f APPLIANCF_S—RESIDENTIAL � C1 PLUMBING RGPIPE
F=y ARCHITECTSDF.CIARATION I PANELS []MULTIUNIT ❑STRUCTURAL.
Z O nor
I understand my plans shall he used as public th. MODIFICATION
O Z� UP TO 200 AMPS
O ❑INTERIOR [I CHIMNEY REPAIR
f•4W.2 Licensed Professional 201-1000 AMPS IMPROVEMENT
Y .4 Oat I am exempt
from
DECLARATION OVER IDW AMPS ❑BATH REMODEDREPAIR ❑DEMOLITION
P: 6 I hereby affirm that 1 em exempt from the Contractors Co License Law for the
•3 O y U (allowing reason(Section 1onsu Business and Professions Code Any city or county SIGNS ELECTRICAL ❑OTHER
V.F which requires u permit to consumer,alter,improve,demolish,or repair any swnum
poor o its issuance.also requires the applicant for such Permit to file a signed statement SPECIAL CIRCUIT/MISC.
yNat he is licensed pursuant to the previsions of the Contractors License Lew tChepler9
�0y (cammemcing with Section 70l of Division 3 of the Business and Professions Cole)or THEIR METER OR POLE INST. COMMERCIAL:
e W that he is exempt therefrom and the basis bathe alleged excitation.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
4, Section by any applicant subjects the applicant a civil penalty of POWER DEVICES
�y ❑TENANT ❑FOOD SERVICE
�ZZZZ}G not mort Nan 0).
five hundred dollars($50IMPROVEM
❑L as owner ofthe property,or my employee.with wages as their sale compensation, SWIMMING POOL ELECTRIC
will it,,the work,umd the suasion,is not immrde nr offered fnr sale(Sec.7144.Business ❑OTHER
and Professions Cale:The Contrdcmr's License Law does not apply to an owner of OUTLETS—SWITCHES—FI(TU
n' r progeny who builds or improves thereon,and who doessuch weak himutfor through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR T.
sale.If.however the building or improvement is sold within one year ofcompletion,the SQ.MiLl $/SQ.IT.
ownerbuilder,will have the bu den of proving that he did not build or improve for put.
pnae.fmic). m C17�' r Ur \
❑1,as owner of the property,aexclusively comon ing with licensed mrs camtmcto TOTAL:
crew Low
the project ppty 7(44,Business rop Professions ds or i The es Amman, n 1 /
cense Luw duce not uhply m is with
of property who sed p or improves Contra,and QTy. PLUMBING PERMIT FEE
who eommds for each projems with a conuocmr(s)license)pursuant to the Contractor's
License Lew. PERMIT ecISSUANCE ®�
❑1 am exempt under S . B&P C far this reesrm
Date ACI'ER—DRAIN&VE WATER(EA) VALUA ON
Owner WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE CoL/h �urtH(1N
1 hereby affirm under penalty of perjury one of the following declarations:
•I]In.....it will mmrteina CenificateofCnn>emmself-insurtfor Worker's Compem DRAINS—FLOOR,ROOF,AREA,GOND. STORIES TYPH CONSTRUCTION
smion,as....tried for by Section 3700.f the Lulxrt Code,for the perfnrmunce of the
work for which this permit is issued. FIXTURES—PER TRAP
❑1 have and will maintain Wodrefs Compensation Insurance,m tequhed by Section
3700 ofthe Labor Code,for the performance ofthe work for which this permit is issued. GAS—EA.SYSTEM-I INC.4 OUTLETS OCC iC�ROUP APN
My Worker CJmne sutiory3nsJusrun,R cartie.wily No: Kh796 GAS—Eh SYSTEM-OVER4(EA) EC
Cartier: 'Y/""�•uu �f" LLQ✓ s 1996
CERTIFICATECOMPENSATION INSURANCE
WORKERS' GREASEANDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE - B 1 IVISION FEES
IThissuOnnnuJ not be complete)if the permit is bounce hundred dollars is 100) GREASE'IRAP
or less.) PLANCNECK F'BC
I cerl that in the performance ofthe work forwhich this permit is issued,i shall SEWER—SANITARY—STORM EA.200 FT.
not employ any pe.a in any manna sa as m hth
eemse subject to e Warkers Compem ENERGY FEE
O Z ..tion Laws of Califon ia.Dare WATER HEATER WNENT/ELECTR
0 Applicant GRADING FEF,
NOTICE'IO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTF.MRREATING
abecame subject to[be Worker's Compensation provisions of the labor Cale.you must SOILS TEE
{kl forthwith comply with such provisions or this permit shill be created revoked. WATER SERVICE
� Z CONST RUCTION LENDING AGENCY NEW RESIDENTIAL PLMIL SQ.FT. PAID
L) 0 Iherebyaffrm that Them isocomuvaionlendingageneyfortheperforprommof Data Receipt
the work fur which this permit is issued(Sec.3097.Civ.C.)
O Lenders Name TOTAL:
Lenders Address T
fit I certify that 1 have read this application and state that the above information is BUILDING FEE
tel examet.I agree to comply with all city and county ordinsacesund state laws relating to QTY. MECHANICAL PERMIT FEE
V building coustractiomand hereby authodm representatives ofthis city to enter upon the SEISMIC FEE
above-mentioned Property for inspection purposes, IPIiRMIT ISSUANCE
(We)agree m sive,indemoily and keep harmless the City of Cupertino against ELECTRIC FEE
liabilitiea,judgmem.:cueu and expenses which may in any way aceraeegmimt.edd City ALTER OR ADDTO MECIL PLUMBING FEE
Lk
in canuquentt of the among oftbis permit.
APPLICAN D <STAN AND WILL COMPLY WITH ALL NONTOINT AIR HANDLING UNIT(TO 10,000 CFM)
MECIIANICAL FEH
SOUR � L '10
AIR HANDLING UNIT(OVER 10,00)CPM)
Z CONSTRUCTION TAX
Si umrt ApplicnnoConuactor Date EXHAUST HOOD(WMUC17 HOUSING MITIGATION FEE
HAZARDOUS ATERIAIS DISCLOSURE
Will the applicant or future budding occupant store or handle hazardous material IIUATING UNIT'G'O RIIJI(E0IITU)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Section 25532(0)? HEATING UNIT(OVER 100,000 BTU)
❑Yes ❑No VENTILATION PAN(SINGLH RE.SID) PAID
Will the applicant or future building occupant use equipment or devices which Dare Receipt M
emit hamNous tim,onmminsms as defined by the Bay Area Air Quality Management BOILER—COMPT3HP OR 100,000 BTU)
D .TOTAL:
❑Yes E]No BOILER—COMP(OVER 11gl,000 BTU)
I have read the hazardous lmtmrials requirenmms under Chapter 6.95 ofthe Cali AIR CONDITIONER ISSUANCE DATE
WIh
y Code,Sec'in,23505,25533 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.FT.
eady cwnLthm it is my responsihilirymnotif the uccupnm
hlc m he a nnlssu ineeofaCenificemo Dec rte ag m TOTAL: ISSUED BY:
OFFICE